You can always press Enter⏎ to continue
CSS Client Satisfaction Survey
Hi there, please fill out and submit this form.
11
Questions
START
HIPAA
Compliance
1
How would you rate your overall experience with Cancer Support Sonoma?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Previous
Next
Submit
Press
Enter
2
How would you rate the CSS Patient Navigator?
Responsiveness
Knowledgeability
Friendliness
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Responsiveness
Knowledgeability
Friendliness
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Previous
Next
Submit
Press
Enter
3
How would you rate the Cancer Support Sonoma clinic space and office?
Comfort of the treatment room
Cleanliness of CSS clinic space
Location/parking accessibility
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Comfort of the treatment room
Cleanliness of CSS clinic space
Location/parking accessibility
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Previous
Next
Submit
Press
Enter
4
Which service(s) did you receive at Cancer Support Sonoma?
Oncology Massage
Acupuncture
Counseling/Psychotherapy
Group Support Session
Health Navigation/Intake
Jin Shin Jyutsu
Lymphatic Massage
Naturopathic Consultation
Ayurvedic Consultation
Other
Previous
Next
Submit
Press
Enter
5
Please rate your satisfaction with the specific services you received.
Mark N/A if you did NOT receive that service.
N/A
Not Satisfied
Somewhat Satisfied
Satisfied
Very Satisfied
Oncology/lymphatic Massage
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Acupuncture
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Psychotherapy
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Therapeutic Massage
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Group Therapy Session
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Jin Shin Jyutsu
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Naturopathic Consultation
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Oncology/lymphatic Massage
Acupuncture
Psychotherapy
Therapeutic Massage
Group Therapy Session
Jin Shin Jyutsu
Naturopathic Consultation
N/A
Row 0, Column 0
Not Satisfied
Row 0, Column 1
Somewhat Satisfied
Row 0, Column 2
Satisfied
Row 0, Column 3
Very Satisfied
Row 0, Column 4
N/A
Row 1, Column 0
Not Satisfied
Row 1, Column 1
Somewhat Satisfied
Row 1, Column 2
Satisfied
Row 1, Column 3
Very Satisfied
Row 1, Column 4
N/A
Row 2, Column 0
Not Satisfied
Row 2, Column 1
Somewhat Satisfied
Row 2, Column 2
Satisfied
Row 2, Column 3
Very Satisfied
Row 2, Column 4
N/A
Row 3, Column 0
Not Satisfied
Row 3, Column 1
Somewhat Satisfied
Row 3, Column 2
Satisfied
Row 3, Column 3
Very Satisfied
Row 3, Column 4
N/A
Row 4, Column 0
Not Satisfied
Row 4, Column 1
Somewhat Satisfied
Row 4, Column 2
Satisfied
Row 4, Column 3
Very Satisfied
Row 4, Column 4
N/A
Row 5, Column 0
Not Satisfied
Row 5, Column 1
Somewhat Satisfied
Row 5, Column 2
Satisfied
Row 5, Column 3
Very Satisfied
Row 5, Column 4
N/A
Row 6, Column 0
Not Satisfied
Row 6, Column 1
Somewhat Satisfied
Row 6, Column 2
Satisfied
Row 6, Column 3
Very Satisfied
Row 6, Column 4
1
of 7
Previous
Next
Submit
Press
Enter
6
Were there any barriers to your ability to obtain services at CSS?
If so, please describe them here.
Previous
Next
Submit
Press
Enter
7
What other types of services would you like to see at CSS?
Please describe them here.
Previous
Next
Submit
Press
Enter
8
Do you have any other suggestions or feedback?
If so, please share them here.
Previous
Next
Submit
Press
Enter
9
Do you want to submit this survey anonymously?
You may leave your name at the end of the survey if you would like to be contacted about your responses.
YES
NO
Previous
Next
Submit
Press
Enter
10
May we quote your feedback in our future promotional materials?
Quotations will be anonymous and/or de-identified to protect privacy.
YES
NO
Previous
Next
Submit
Press
Enter
11
Share your name here.
OPTIONAL
First Name
Last Name
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
11
See All
Go Back
Submit
